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Inpatient Hypertension

Nicholas Weinand

Background

  • Hypertensive urgency: SBP > 180mmHg/DBP > 120mmHg
  • Hypertensive emergency: SBP > 180mmHg/DBP > 120mmHg + end organ damage

Evaluation

  • Are there signs/symptoms of end organ damage?
    • Neurologic symptoms: agitation, delirium, stupor, seizures, visual disturbances
    • Focal neurologic deficits
    • Chest pain
    • Back pain (consider aortic dissection)
    • Dyspnea (consider pulmonary edema)
    • BMP, LFTs, Troponin, BNP: Lab findings suggestive of end-organ damage

Management

  • Goal is to lower BP back to normal over 24-48 hours
  • Initial lowering should be 10-20% in minutes if HTN emergency; goal should be 10-20% in 2-4 hours if HTN urgency
  • Typically aim for initial goal BP near 160/110
  • Exceptions to gradual lowering include:
    • Acute stroke: call code stroke, lower ONLY if BP > 185/110 in pts under consideration for reperfusion therapy; or BP > 220/120 in pts not candidates for reperfusion therapy
    • Aortic dissection: Goal = rapidly lower BP in minutes to target of 100-120 systolic to avoid aortic shearing forces

  • Pharmacologic therapy

    • Ensure their home medicines have been restarted at appropriate doses, formulation (long acting vs. short), and dosing intervals
    • If pt has a rapid acting anti-HTN med, can consider giving a dose early or an "extra dose" and then up titrating their overall daily dose

  • Rescue therapies

    • Captopril PO (12.5mg or 25mg dosed Q8H; conversion ratio of captopril:lisinopril = 5:1)
    • Hydralazine PO (10-20mg initial dosing Q6H)
    • Isosorbide dinitrate PO (5-20mg TID)
    • Nifedipine XL PO (dose at 30mg initially, max 90 mg BID; NOT sublingual)
    • Labetalol IV (10-40mg initially; dosed up to every 20-30mins)
    • Hydralazine IV (10-20mg initially; dosed up to every 30 mins).
    • Nitropaste 1” (can add/wipe away for titration; dose Q6H until oral meds can be started for better long-acting control)
  • Dialysis if missed session

Additional Information

  • Refractory HTN: try additional agents listed above vs. escalation of care for drip (nicardipine, nitroglycerin, nitroprusside, esmolol).

  • Most drips that can be done for this indication are done in stepdown and usually require no-titration of the infusion and occasionally the MD to be bedside to initiate the infusion.

  • This includes diltiazem, labetalol, nitroglycerin, and verapamil drips. Nicardipine, esmolol, and nitroprusside drips are not allowed on step down.